LIVESTRONG Intake Form

The Intake Form Process


1. Complete the following intake form to help us understand how we can best support you.
2. You will be asked questions about yourself, your loved one or client diagnosed with cancer as well as what services you are looking for.
3. You will hear from LIVESTRONG within 1 business day.
4. LIVESTRONG will help you connect to resources specific to your individualized needs and provide you with information on the next steps.

If you would prefer to talk with someone by phone, please contact us Monday-Friday, 9am-5pm CT, toll-free at 1-855-220-7777. View our Holiday schedule.

Any information that is provided to LIVESTRONG is kept confidential and not provided to anyone outside of LIVESTRONG without your consent.
All services are free of charge and clients are not withheld services based on age, race, ethnicity or immigration status. However, if you are under the age of 18 and completing this form, we will need parent/guardian consent to follow up with you about the resources we identify for you.

The intake form will take approximately 1—5 minutes to complete.

* information required

My Primary language is (Su lengua preferida es):*
English
Español
I am seeking help for*
Myself - I have/had cancer
Myself - a family member or loved one has cancer
Patient/Client - I am a health professional
I prefer not to answer
First Name*
Last Name*
Best form of contact
Preferred Contact Time*
Email
Phone
  
;